Facing low ovarian reserve can feel overwhelming — but with the right guidance and tailored strategies, success is still possible.
In this live session, Dr Mariliz Hatzipanteli, Infertility Specialist at Newlife IVF Greece, shares practical, evidence-based approaches for women with diminished ovarian reserve, supported by real patient case studies.
Hosted by Liadh Fitzgerald, CEO & Founder of Women’s Health Network (WHN), this session is packed with clarity, science, and hope.
Low ovarian reserve, also referred to as diminished ovarian reserve, is one of the most challenging diagnoses in fertility treatment. In this educational session, Dr Mariliz Hatzipanteli explains what low ovarian reserve means, how it is diagnosed, and how IVF protocols can be carefully tailored to improve outcomes, even in complex cases.
Drawing on both clinical evidence and real patient journeys from NewLife IVF Greece, Dr Hatzipanteli highlights that while success is not guaranteed, personalised treatment and realistic counselling are essential parts of care.
Several markers are used to evaluate ovarian reserve. The most commonly used include:
Anti-Müllerian hormone (AMH)
Antral follicle count (AFC) measured by ultrasound
Follicle-stimulating hormone (FSH)
Oestradiol levels
Dr Hatzipanteli noted that AMH and AFC are currently the most reliable indicators. When AMH is low, and AFC shows fewer than five follicles on baseline scan, a woman is likely to be classified as a low responder to ovarian stimulation.
Age is the most common factor, but it is not the only one. Dr Hatzipanteli outlined several potential causes, including:
Previous chemotherapy or cancer treatment
Genetic factors
Autoimmune conditions
Idiopathic causes, where no clear reason can be identified
In many cases, women are diagnosed with low ovarian reserve without a clear explanation, which can be particularly distressing.
To help predict how a woman may respond to IVF stimulation, several prognostic models have been developed. Dr Hatzipanteli referred to the Bologna criteria and the more recent POSEIDON criteria.
According to these classifications, women with an AFC below five or AMH below approximately 1.2 ng/ml are expected to respond poorly to stimulation. This usually means:
Fewer eggs retrieved
Lower fertilisation and blastocyst development rates
Higher risk of cycle cancellation
Understanding this prognosis helps guide realistic expectations and treatment planning.
Low responders typically produce fewer eggs despite stimulation. Dr Hatzipanteli explained that this does not mean pregnancy is impossible, but it does mean that IVF treatment is often more complex and may require multiple attempts.
Lower egg numbers are associated with:
Reduced chances of obtaining embryos
Fewer embryos available for transfer or freezing
A longer and more emotionally demanding treatment journey
Evidence-based guidelines recommend conventional IVF as the first-line approach for women with low ovarian reserve. Dr Hatzipanteli explained that both agonist and antagonist protocols are acceptable, as antagonist protocols have not been shown to be inferior.
Mild stimulation has also been explored, but current evidence does not support the routine use of modified natural cycles for low responders.
Clomiphene citrate may be used in combination with gonadotropins in selected cases, but letrozole has not shown benefit in this patient group.
Many women with low ovarian reserve ask about supplements and add-on treatments. Dr Hatzipanteli addressed several commonly discussed options:
Growth hormone: not supported by evidence
Testosterone: not recommended for low responders
DHEA: not recommended; strong evidence against routine use
Platelet-rich plasma (PRP): still experimental
Stem cell therapy: experimental
She emphasised that while these treatments are frequently discussed online, current guidelines do not support their routine use.
Double stimulation can be used to maximise egg retrieval within a single menstrual cycle. This involves stimulating the ovaries, collecting eggs, and then immediately stimulating again to recruit remaining follicles.
Dr Hatzipanteli explained that this approach may help retrieve more eggs in a shorter timeframe for selected patients, although it is not suitable for everyone.
To illustrate how IVF can be tailored for low ovarian reserve, Dr Hatzipanteli shared several real cases from her clinic.
One 36-year-old woman underwent a standard antagonist protocol and produced only two eggs, resulting in one embryo. A second attempt produced no embryos. She transferred the embryo from the first cycle and achieved a live birth.
Another patient had a more difficult journey. She initially underwent an agonist protocol and retrieved only one egg with no embryos. The protocol was changed to clomiphene combined with FSH. After multiple cycles and protocol adjustments, she eventually produced four eggs, resulting in three embryos. Transfer of two blastocysts led to a live birth.
A third patient pursued natural cycle IVF. Her journey included five aspirations and four cancelled cycles. Over time, two embryos were obtained, and a frozen embryo transfer resulted in a live birth.
One particularly striking case involved a 44-year-old woman who did not respond to a conventional stimulation cycle. After discussion, she chose to try again using testosterone pre-treatment and an agonist protocol. The response was very slow, and the cycle was cancelled. Unexpectedly, she conceived naturally a few weeks later.
Dr Hatzipanteli stressed that while many positive outcomes are possible, not every patient will achieve success. IVF for low ovarian reserve can be financially, physically, and emotionally exhausting.
She emphasised the importance of discussing alternative options, including:
Egg donation
Embryo donation
Adoption
Psychological counselling and emotional support
Talking to others with similar experiences can also be helpful for many patients.
Dr Hatzipanteli concluded with a message of cautious optimism. While low ovarian reserve presents significant challenges, personalised care and informed decision-making remain central to treatment.
Impossible is nothing, she said, while also acknowledging that every patient has limits and that sometimes the journey needs to change direction.
Her message encourages patients to remain informed, supported, and realistic as they navigate fertility treatment with diminished ovarian reserve.
There is no direct connection between ovarian reserve and add-ons such as embryo glue or PGT-A. Low ovarian reserve mainly affects how easy it is to create embryos. It is not directly related to implantation or recurrent miscarriage. The main challenge is reaching the stage where embryos are available because of attrition rates in IVF, especially when only one, two, or three eggs are retrieved. However, when an embryo is available, it can be reasonable to use all available options to try to improve implantation, even if the benefit is small.
Some believe that low AMH may also affect quality, but this has not been officially proven. In my examples, most women were under 40 years old, so we would expect their embryos to be normal. It may be difficult to obtain embryos, but when embryos are created in younger women, we generally expect good quality and reasonable pregnancy rates after transfer.
It is not very common, but it does occur. Long-term hormonal contraception has been associated with lower AMH levels. It is believed that AMH may increase 6 months to 1 year after stopping hormonal contraception. This is one of the first factors I ask about. While low AMH is not typical in young women, it does happen.
The evidence regarding DHEA is very clear: it does not improve pregnancy or live birth rates. At present, there is no evidence to support the routine use of supplements. Testosterone may be beneficial in some cases, but it should not be routinely recommended.
This is a very personal decision and depends on the individual. Some younger women with a reasonable prognosis choose not to try with their own eggs at all. Others make this choice for financial reasons or to avoid the emotional stress of repeated unsuccessful treatments. Some may choose egg donation as a first option, while others prefer to try several IVF cycles first. Cultural, religious, and personal beliefs also play an important role.
First of all, do not panic. Low AMH does not mean that a woman cannot conceive naturally, especially if there are no other fertility issues and she has not been trying for a long time. Low AMH alone is not a diagnosis of infertility. If treatment is needed, the journey can be long and challenging, and patience is essential.
PRP is generally considered a rejuvenation technique. It is used in various areas of healthcare, including dermatology and hair loss. The idea is that it may help regenerate or rejuvenate ovarian tissue. I cannot be very specific about the exact mechanism, but this is the general rationale behind its use.
Yes, AMH is usually the first marker used to assess ovarian reserve. However, couples are typically advised to seek treatment after trying to conceive for at least two years, and many will not have had an AMH test during that time. Low AMH alone is not a reason to avoid trying naturally. Many women with low AMH conceive without difficulty. If a young woman discovers low AMH without having tried to conceive, I would advise her to try naturally first and repeat the test after six months to assess any change
It is difficult to answer without knowing the size, location, and extent of the surgery, as well as how the uterus has healed. While it is not an ideal diagnosis or procedure, it does not automatically mean that pregnancy is impossible. The situation may be more challenging, but a chance still exists.
